Medication Cessation

Key points:

1. patients who are on 5 drugs or more are at an increased risk, up to 30 %, of experiencing an adverse drug-related event (ADE) over the next 6 months, which may lead to hospitalisation.

2. When reviewing medications for patients who are on multiple medications, the following issues need to be established:

• the current indications for each drug
• Patient and carer's perception of the efficacy and side effects Phyllis has experienced with each drug
• whether there are any drugs she is not taking and reasons for non compliance
• scientific evidence for the benefits and harms of each drug
• a shared understanding with patient of the likely future course of illness and what she values as the goals of care

3. The CEASE protocol includes a systematic method for appraising the utility of individual medications and deciding which ones may be worthy of discontinuation and in which order. The following 6 questions are there to help with the process:

• Is there a valid indication for each medication?
• right diagnosis? active disease?
• evidence to use those medications?
• Is the drug part of a prescribing cascade seeking to counteract side effect of other medicines?
• Is the drug, on balance, more likely to do harm than confer benefit over the medium to longer term?
• Is the drug being prescribed for disease or symptom control despite either being ineffective of where symptoms have completely resolved or are amenable to non-drug interventions?
• Is the drug a primarily preventive medicine, which is unlikely to confer any patient-important benefit over the patient's remaining lifespan?
• Is the drug imposing unacceptable treatment burden?

4. The drugs that should take priority in being discontinued are those with the lowest utility and least likelihood of being associated with withdrawal syndromes or disease rebound. (Figure 1 Algorithm for deciding the order and mode in which could be discontinued)

5. Cease one drug at a time so that harms and benefits can be attributed to specific drugs and rectified.

6. Wean, not abruptly cease, drugs that are more likely to cause adverse withdrawal effects. Instruct the patient on what to look for and report in the event of such effects occurring, and what actions they can self-initiate if these were to occur

7. Fully document the reasons for, and outcomes of, de-prescribing